Doctor Mariya B, Chaudhary Simmy, Senthil Sirisha, Basu Sayan
The Cornea Institute, KAR Campus, L V Prasad Eye Institute, Hyderabad, Telangana, India.
V S T Centre for Glaucoma Care, KAR Campus, L V Prasad Eye Institute, Hyderabad, Telangana, India.
Int J Surg Case Rep. 2022 Sep;98:107505. doi: 10.1016/j.ijscr.2022.107505. Epub 2022 Aug 13.
This case demonstrates an unusual presentation of Herpes simplex virus (HSV) ocular infection and the challenges faced during the management of its complications.
A thirty year-old lady, a steroid responder with HSV keratouveitis, was referred for non-response to treatment with the prophylactic dose of oral acyclovir and acetazolamide. She presented with large epithelial bullae, anterior chamber reaction, and raised intraocular pressure in her right eye. Initially, she responded to the therapeutic dose of oral acyclovir, but on follow-up visits, she developed high intraocular pressures of up to 45 mmHg on maximum medical therapy. Hence, trabeculectomy with mitomycin-C was performed. One year later, she developed corneal endothelial decompensation, for which a Descemet's stripping automated endothelial keratoplasty (DSAEK) was done. Eight months post-operatively, she had a best corrected visual acuity of 20/20, clear corneal graft, quiet anterior chamber, and well-controlled intraocular pressures.
HSV trabeculitis is associated with inflammation of the anterior chamber, endothelitis and raised intra-ocular pressure. A combination of anti-viral, anti-inflammatory, and anti-glaucoma medications helps in the management. However, glaucoma filtration surgery is often needed to the control intra-ocular pressure. Chronic recurrent episodes eventually lead to endothelial failure and demand endothelial keratoplasty (EK). It is prudent to adopt certain measures to perform EK in these phakic eyes without causing any iatrogenic damage to the filtration bleb as well as to the clear crystalline lens.
This case highlights the difficulties of treating HSV-related keratouveitis with uncontrolled glaucoma, problems of associated steroid response, and complexities in performing corneal endothelial procedures in young phakic patients especially post-trabeculectomy.
本病例展示了单纯疱疹病毒（HSV）眼部感染的一种不寻常表现以及在处理其并发症过程中所面临的挑战。
一名30岁女性，患有HSV角膜葡萄膜炎且对类固醇有反应，因口服阿昔洛韦和乙酰唑胺预防剂量治疗无效而前来就诊。她右眼出现大的上皮水泡、前房反应和眼压升高。最初，她对口服阿昔洛韦治疗剂量有反应，但在后续随访中，即使采用最大药物治疗，她的眼压仍高达45 mmHg。因此，进行了丝裂霉素C小梁切除术。一年后，她出现角膜内皮失代偿，为此进行了Descemet膜剥脱自动内皮角膜移植术（DSAEK）。术后八个月，她的最佳矫正视力为20/20，角膜移植片清晰，前房安静，眼压得到良好控制。
HSV小梁炎与前房炎症、内皮炎和眼压升高有关。抗病毒、抗炎和抗青光眼药物联合使用有助于治疗。然而，通常需要进行青光眼滤过手术来控制眼压。慢性反复发作最终会导致内皮功能衰竭，需要进行内皮角膜移植术（EK）。在这些有晶状体眼中进行EK时，采取某些措施以避免对滤过泡和透明晶状体造成任何医源性损伤是明智的。
本病例突出了治疗伴有未控制青光眼的HSV相关角膜葡萄膜炎的困难、相关类固醇反应问题以及在年轻有晶状体患者尤其是小梁切除术后进行角膜内皮手术的复杂性。
